Miller/Greenfield/Carroll: Hamilton T1 for Ground EMS (3/1/24)

Okay. Welcome, everybody. It is Friday, March 1, 2024. We have a lot of people showing up today for this webinar. I knew that would happen. We have some great guests today. And as you know, we have brought in. We typically bring in folks who are doing a lot of research, and then every now and again, we like to bring in clinical folks who are actually doing things in the field that.

That many people are not doing. And we'd like to hear from those folks. And today is one of those presentations. I have been gotten to know Jesse Carroll very closely recently. I've known Dr. Brett Greenfield for quite a while and got to have dinner with him recently in person. Gordon, you and I never met, but I heard lots about you. And Gordon is from desoto Parish ems. And what I wanted to do today was really describe or have people who are doing this actually come onto the webinar and talk about the use of a ventilator. Really, in ground ems, we know the air folks are using ventilators. That's obvious. But we thought this kind of little duo of Gordon and Brett would be very good for us to kind of learn and see what others are doing out there. Jesse, obviously on the Hamilton team, who's truly an expert. I mean, Jesse probably one of the smartest folks that I've met, and his ventilator knowledge is just second to none. So without any further ado, I'm going to stop sharing my screen. And if you guys want to make a few intros. So we'll start with Brett, go to Gordon, and then Jesse, and then we'll let you guys take it away. Thanks for coming on, guys.

Appreciate it. Peter. Good morning, everybody. So excited to be here. We've been talking about this for quite some time. Glad this day is here. My background is I am a EMS physician, emergency physician, and both flight and ground medical director. I started my EMS career back in 1988 and have just watched the specialty evolve. So excited to be here with Jesse. What I love about this is that you're able to increase your network. Never met Gordon before, but we had a nice conversation about a week or two ago. So excited to be here and ready to talk about mechanical ventilation in the EMS world.

Awesome. Thank you so much. Brett Gordon.

Gordon Miller. I've been in EMS for about 23 years now. I've been at DeSoto EMS for 20, SWAT Medic for 15. That's some fun stuff. Flew in a helicopter in Shreveport for about five years. Kind of where I started my ventilator journey pretty much now I'm a shift supervisor. I help with clinical development and high acuity training in DeSoto Parish. The cohort on here, Brent Crawford, you may be able to tie in some of his event stuff as well. So that's pretty much my experience.

Awesome. Thank you so much, Gordon. And then Jesse.

Hey, good morning, y'.

All.

Thank you again for having me on here, Peter. So, yes, the EMS accounts manager for both the state of Florida and Georgia. Now, I've been in critical care for 12 years as a respiratory therapist, primarily NICU, PICU and ECMO through Shands UF up in Gainesville and then down here in South Florida as well.

And just got to being here at Hamilton. Hamilton gives us the ability to really get real well connected with the clinicians like Gordon and like Dr. Greenfield that are out there really leveraging the power of these devices to not only impact patient care, but more importantly, where sometimes it kind of goes by the wayside is how does it impact the rescuer?

Right.

So me having an opportunity to work with them and then have them discuss their experiences with it on here on your webinar, Peter, is sensational, frankly.

Awesome. Well, thank you so much, Jesse. All right, so is there an order? Is it going to be Gordon going to go first or. And if you have slides, you guys can just go ahead and share away. So, guys, take it away. Thanks for coming on.

So I'll share this first one.

And I want to make it clear, everybody watching that as far as knowledge events and things like that, every agency has their shower singers, cover band singers and rock stars. The T1 makes it easy for everybody to use. This first one is going to be a cardiac arrest. This was kind of post Covid error. What was interesting about this and why I wanted to bring it here was the patient actually died of a massive pe. I intubated the patient, saw it go through the cords, it was done with vl, hooked him up to inside, of course, gold standard immediately, and nothing. And it's kind of surprising, like, what's going on here? We had another monitor. I was in a supervisor vehicle at that time, just grabbed my monitor, hooked him up to that. Still nothing. There was no entitle whatsoever. And of course, we know that we don't have end tidal. We can't really consider them intubated. Of course, we have all these other signs. And of course, my resolution, that was our T1 airflow sensor. So that's what really was confirmation to us that, hey, absolutely, this patient is intubated.

It's very simplistic using it. I Was actually using this for CPR before CPR mode was cool. As I say, I come up with a guideline. You would have to go into modes and configure it yourself when you had a cardiac arrest. I had used this ventilator numerous times for cardiac arrest in patients and we would have ROSTAM changed to asv. And one of the amazing things is, is when you swapped in the ASV and that patient was allowed to start spontaneously breathing, you would see up into the 20 liters a minute those patients were compensating, trying to blow that acid off. Which was really phenomenal to see that because obviously we know if we're bagging them, that's not going to be something we're going to do. We're going to give that patient standard, you know, 12, 15 breaths. We're going to look over here at our end tidal, letting that patient spontaneously breathe. That was an amazing thing to see. Have had no issues with as far as CPR mode. The biggest compliment I get are from the individuals who work here part time that do not have the ventilator at their full time position. They basically say that they almost feel like they're completely work free when they're working on cardiac arrest. You know, you have the CPR machine going, you have that, the Hamilton going from the first breath, get them hooked up to that, hit CPR mode, let it go. If you have rosc, we simply swap to asv. It's a very seamless transition to that. Have nothing but great things to say about that.

Gordon. Just, just real quick for, for those of people who don't know, you know, asv, it's, et cetera. Are your medics basically just turning on the device, turning to an age, male, female and then clicking on asv. And I mean, is that, is that essentially what you're doing and the machine just kind of starts to work 100%.

I have basically over the years come up with pre selects basically. So when you turn our home screen you have, and this was from a gentleman's idea, that was an older medic that is like, hey, make it very simple for me. I initially had it labeled as asv, BIPAP and cpap. And he simply said, can you just name it Intubated, COPD and chf. I'm like, absolutely. And when you turn on our ventilators, that's the home screen. You get intubated, go straight to ASV with the settings that I have pre programmed in it. You set that patient either male or female and then their height and from there it does its thing. And I would say it literally works 99.9% of time in our ground EMS world, we're not talking about going and picking up these really sick ICU patients and transporting ECMO centers or anything like that. Talking about acutely ill, cardiac arrest, copd, chf, all those patients. It works phenomenal on. And I'm the person that the contact person call if you have an issue with event, you call me and had a few calls the first year we implemented it. After that, not so much. Haven't heard a peep. It's been working seamlessly for everyone. And I can say there's probably about maybe five times that I've actually taken the vent out of ASV mode and that may be some kind of special circumstance. And one I'll go over kind of later on we can talk about with that.

I'll just add to that from a clinical note, Peter, just to kind of, when you say it just kind of. The vent does what it does, what makes it so special is we leverage the power of a proximal flow sensor. That proximal flow sensor is directly connected to the patient's airway that is measuring 200 data points per second to include calculating the static lung compliance and the airway resistance on a breath by breath basis, which we all know dynamically changes when we're on the chest, compressing the chest during a resuscitation effort. And then in a post resuscitation ventilation scenario, we have no idea the pulmonary mechanics of these patients. They're likely underinflated and compressed quite a bit. So that's where the power of that proximal flow sensor is a game changer that Gordon's kind of referencing there.

Yeah. Just to comment real quick, real quick, Peter, is, you know, adaptive support ventilation. Jesse always talks about this not being a mechanical ventilation mode. It's a mechanical ventilation strategy that allows the machine, as Jesse talked about, leverage the technology to assist the clinician. We always hear about set and forget that's not what this is all about. But it provides a framework to allow you to mechanically ventilate your folks very safely and effectively and provide feedback.

Right.

One of the issues with some of the simpler devices that we use in the EMS world, including BVMs, you know, disposable CPAP, the clinician doesn't get feedback. And this device is safe, effective, and it provides a lot of feedback, which is super important.

And I'm glad that you mentioned that because, you know, here we are, you know, we have Large agencies and we're trying to deploy a ventilator of some sort. That's why we're kind of looking into all these different ones. And it's, it's difficult. You know, Brett, as you know, Gordon knows this as well, is that when you have, you know, we, we work with thousands of paramedics. You know, one agency alone has 1600. And to, to try to deploy a complex, a complex device or complex procedure that they may only use every now and again is something that I've, I've avoided, to be quite honest with you. So.

That'S good information. So, all right, so Gordon, you want to take us to the next, to the next case.

So this is one. And then again, it's something that we've been using the Hamilton's almost a decade, so eight years. There's very, very little that surprises me with this event anymore. So I really had to dig in and say, hey, let me find some very surprising, really interesting cases. This is one that I was actually the primary responder on. I still, even though I'm a supervisor, do write on a medic unit occasionally. I think it's important to get perspective where you're the sole ALS provider sometimes and know what your guys are going through and gals are going through. This patient was a teenage patient that took what he thought was a, some type of oxycodone pill. It ended up being fentanyl and it almost killed him. Thankfully, the other teenagers that were there were mindful and say, hey, you know, we're going to call 9 1. We're not going to get scared. The sheriff's officer is literally right next door. They have a substation en route. We just pretty much got that it was a teenager that was unresponsive, not breathing. Then it come back, said, hey, sheriff's office performing cpr.

So we get there and you can kind of go into the kind of narrative real quick. And like I said, I was a sole proprietor on this at first. So I can just go through it. When we walked through the door, Patient was the color of my shirt. He was gray. He was beyond blue. He did still have a pulse. Sheriff's office. Like I said, they were performing cpr. Had a BLS partner with me. I instructed him, hey, to start bagging opa. Let's get that going. I gave him nasal Narcan right before that. It was super fast as far as like what we're trying to do to him. I'm pulling arcan out and going through my mind okay, fast way. I Can get Narcan to him. He has some pretty decent veins. I literally put a 21 gauge needle on the end of a pre filled Narcan. Just went ahead and just a minute or so that way. Didn't have time. Start iv, anything like that. Just trying to get that going with him. His initial OT sat, less than 50, starts coming up with a DVM. We move into a tarp, get him outside to help the sheriff's office. While I'm getting in the medic unit, they're loading him, I'm turning on the T1, getting VL out. I intubate him with no kind of sedation, no paralytic anything like that. Completely passive patient. No gag reflex, no cord clenching anything. And this is after probably 4mg Narcan. Intubating, getting put on the vent. I'm still just holding the tube at this time. Haven't even secured it yet. Looking over the vent, he's completely passive, completely vent controlled at this time. Ventilating the patient and we start seeing him start taking some spontaneous breaths. I actually start having some more ALS providers show at that time, kind of help me out, starting IVs, things like that. At that point, the patient has this sudden increase in lse. Of course, like we see with Narcan, he's still intubated. Now he's 100% spontaneous. This happens within less than probably four to five minutes. This patient goes completely apneic and passive to 100%. He's breathing, looking around, has a little bit of gag reflex. He's not reaching or panicking, trying to grab the tube or anything like that. Kind of lean him up a little bit more. I'm still holding the tube. I have my other supervisor at the time start basically perform a stroke assessment, like, hey, do this. We at least know we can document that easy. He was following commands, he was doing this, he was doing all these, you know, our fast, be fast stroke scale did that very well. I'm watching the ventilator, watching the volumes he's pulling, watching the other predator, saying, hey, he's fine, he can breathe on his own. There's no point at this time in my mind to paralyze him or continue to sedate him. And we extubated him on scene. It went very well, had no issues with it. He literally said he had no recollection of the incident going on. And I just think it was a true testament to this mode and this methodology of ventilation, how fast ASV can adapt to this patient and the changing needs without any user input. Because from the initial time, did I turn it on, fresh start ventilation. I never touched the ventilator until the point where I actually turned it off.

So, so, so just, just. I'm clear here. You're basically saying that you, you started him on asv, he wasn't breathing at all, right?

No, he's completely passive.

Right. And then he was kind of, over the next four to five minutes, he came around and he started taking spontaneous breaths until he became fully conscious and awake and alert.

Correct.

Throughout that time, the actual ventilator adapted to that, is what you're saying.

Absolutely. Without fail, without any user input. It was completely patient driven. The ventilator is looking at every breath, figuring things out, looking for that spontaneous breath, switching in between its modes that it has to do, and literally completely passive to completely conscious, looking around, following commands and basically trying to talk and communicate to the point to where we extubated him.

So let me, let me, let me bring in Brett again here. So, so Brett, you, a minute ago you said that it's, it's not a set it and forget it type of thing, but this case that Gordon just mentioned, that it sounds like it, it's kind of automated most of what it, what it needs to do because of this ability to know what the patient is doing. Can you, can you describe a situation where that, that mode wouldn't, wouldn't be useful as an example? Just so I can get, I'm trying to get a sense here because I'm thinking ahead of, you know, kind of educating other folks.

Yeah, no, no, it's, it's a very fair point. And I probably will ask Jesse to chime in here, you know, for the EMS experience that we've had out, you know, out of hospital ground 911 system. You know, ASV mode really is effective probably in 90 to 95% of our patients. There's clearly some cohorts or small subsets of patients. And I'll actually defer to Jesse because he's the clinical expert here on when it doesn't work. But the reality is, Peter, like, you're sitting there and you're allowing the machine to do what it needs to do, but there are visual cues, there are alarms that let you know, what is this patient doing? How effectively are you mechanically ventilating your patient? Is the patient working on their own? Are they meeting their needs with volumetric capnography, with measuring expired tidal volume? And you can learn a lot and you can adjust based upon that. I mean, when we first started this Whole process, it was tough. We went with a ventilator that did not give you a lot of feedback and there was a lot of alarm fatigue and the clinicians got very frustrated. So it was kind of like an evolution of, you know, where do we go technologically? Because again, if you can't get buy in with your folks because of things like that, they just won't use it. They won't use it. Jesse, you're there. Can you comment about that small population of folks that don't require.

Yeah, sure. That, that's great. I appreciate that, Brett. So what I'll say is there's, there's realistically only one true absolute contraindication for the use of asv, being that ASV is a closed loop system of ventilation. And that would be massive air leaks. Like where talking tracheal esophageal fistula, we're talking multiple chest tubes in some of the patient populations that Gordon Miller mentioned earlier. The really bad ARDs or post Covid in the 2020 Covid rush that we saw where we just could not perfuse these patients where it struggled. And obviously if you cannot close the loop, we can't go there. But the key takeaway here is, look, ASV leverages when you go into the mode section of the T1, the volume controlled settings, which would be APV, CMV, or for those of you that aren't on that nomenclature, it would be SCMV or apv, SIMV or simv.

We're using ASV is using the volume controlled settings. So if you're not using ASV and you're prioritizing setting a volume controlled mode of ventilation, you're just kind of cheating yourself because now you're having to get stuck on what rate do I set, what tidal volume do I set? And this is not the time to be doing this in the field. When you hear this story that Gordon's talking about, right. They have so many other things on the triage tree that they need to prioritize. If they can secure an airway and allow a device that is significantly more advanced than they can clinically adapt to, why would we not leverage that? So it'd be a small patient population that you would want in like a pressure controlled mode where you're really trying to be in control of these patients pressures. But the reality is, Peter and Brett and Gordon, those of you on the call is like, we're not managing these patients in the manner of which they're managed in the hospital. We are trying to get them as safely and as effectively into the facility as quick and as easy as possible. My med don't have that time to sit there and manufacture reproducible ventilator settings. ASV helps to alleviate this by putting them, them and the patient in the best case scenario. So I hope that that helps clear that up.

Yeah, yeah, yeah, that was very good. So we have, we have eight minutes left. I know we have one more case. So Gordon, let me put it back to you. This has been great. This is, this is case number three. Take it away.

All right, so this is what I say is the.

Really your go to. And you hope that hey, this is where I end up. This is the point to where we decrease intubations, decrease our dsi, especially in our COPD population. I went over some of that data. Like I said, I'm clinician, I'm not the best of data guys. But this was easy to look at and see our data about 60% reduction. And I did like providers patients only with GCSE of 15 that were COPD patients. This gentleman here is probably the worst COPD patient I've made in 20 some odd years and not intubated. I had no idea, I had no idea that the non invasive on the T1 could even do this. And it really blew my mind. Get this call of shortness of breath. We get there. I was in a supervisor role that day. When I'm pulling up, I hear the vent alarm going off. So I already know that they've already had him on bypass and step back in the medic unit. This patient severely obstructive, no lung sounds anywhere. Initial O2 sat when the paramedic got there was 66%. Patient had taken approximately three breathing treatments. Of course how they always do you get there and they've taken a half a box of, you know, duonets and things like that. Patient just struggling and the best way I know how to do it sometimes we always search for data and things like that. But I think as all clinicians, we've all been that patient who is severe, severely a ton of just very difficult. You know, their breathing difficulty is beyond what we can imagine. They are looking at us. They have that I'm dying look in their eyes. Their last ditch efforts are almost trying to push themselves up in a bed and they're just, you know, in their stretcher or things like that and they're just too weak to even do that. They're just tired. They're done. I really didn't think non invasive is going to work on this patient and it really opened my eyes to this. This patient went from, you know, GCS 15 to, hey, I'm fixing to intubate him to a O2 set of 90. 100% within minutes. 66% at 22 and we're looking at 93% at 27. It was probably quicker than that that this improved. The moment arrived when we put him on non invasive and I was controlling the vent at that time and I was going up and up on the pressure support. And I'm watching him and he gets this point to where he figures out and you see this look in his eyes and you know that at that point he's like, I can breathe. He starts looking around, he's leaning up, he's comfortable. We're doing all our other treatments going on. And like I said, I can't express to you how bad this patient, how much of a bind they were in. This patient could not breathe at all. Within minutes of having him on the non invasive, his lungs start clearing up. We do all our treatments. We do some IV ketamine, low dose, non disassociative, glycopyrolate, solumedrol, mag, the whole gamut of drugs on him. By the time we got to the hospital, they were taking him off the BiPAP. He was completely almost better at that time. This happened to this gentleman twice in two weeks. And I literally made him with the same cruise. And as soon as I heard that address the second time, it was like alarm bells going off, like, oh, we're doing this again. And it was the same exact incident. So this happened twice within about two weeks. Phenomenal as far as how this worked out for us.

Awesome, awesome. So that was amazing. What I'm going to do is we have a lot of questions and I want to leave some time because we want to get to Dr. Pepe's webinar at the bottom of the hour. So first question comes from Kerry Bachista. This is great. One word of caution. The CPR mode has a positive flow at all times, and if you're using an itd, defeat it. We're going to Hamilton, but will not be using the CPR mode while we're using the itd. Jesse or Brett, can you discuss that?

Yeah, so there.

I'll just take that real quick.

Brett.

So there is a bias flow on the ventilator that is. That will be enough flow to overcome the itd. And I mean, we've all seen the ITD be successful. It's one part of the CPR algorithm. Right. Which is impact the cardiac side.

But without the ventilations, and more importantly, without the optimized ventilations, we're still going to struggle to see the improvement of our long term neurological outcomes. I was just recently reading some of the updates on the heads of CPR as well. So for Gordon, I don't know, I don't believe you guys are using ITDs. Right.

Yeah.

So what I would say also.

Right.

So what I would say overall, Peter, is it might be a word of caution if we're going to continue to move forward with the itd. But if we can balance out this CPR algorithm and equation to where not only do we achieve ros, but we actually achieve optimized ventilation, maybe we even see better outcomes. That would be something we'll have to wait and see as, as more agencies adopt the T1. And more importantly, what are we doing in a post resuscitation ventilation scenario? The T1 still needs to be there for that aspect.

Right.

Okay. All right, so I'm going to keep going here. That's a great answer. So I will kind of wait and see on that. George says. So by using the ASV mode, the other settings aren't required to be set, such as tile volume, PIP rate, et cetera, like you would in Mosaic simv.

That's correct. We are going to, we're going to take a lung protective ventilation strategy to talk from where Brett spoke about earlier. And what we do is we support 100% minute volume based off of ideal body weights delivering 100 mls per kilogram. Right. So for example, I'm a 5 foot 9 male, 71 kilogram ideal body weight. If you were to select 100% minute volume, the vent's going to support 7.1 liters per minute of minute ventilation, which you could then augment from there. And it is not set it and forget it. In that I teach, and we teach a specific algorithm to actually augment your minute volume to get CO2 outcomes as well for a CO2 elimination.

Okay, great answer, Matt Maples. Two things. Is your CPR mode set up in volume or pressure? And then the copy of the recording will be on our YouTube channel. I'll put that in the chat, but who wants to take that one?

Ours is set up in volume and the reason why is because when we initially came up with that mode, it's what everybody's used to. And before, like I said, we didn't have the CPR mode, they would have to manually set it. So basically we're using a, the volume adaptive CMB as Have nomenclature we use for that.

Okay, excellent. Kim. Kim. Dr. Kim Landry does the Hamilton then make adjustments based on the peak inspiratory pressure as well as the plateau pressures.

So the significance of what the T1 does is the T1 is actually going to show you the driving pressure. Under a monitoring tab. We actually show that driving pressure which adding the peep to that actually shows the clinician breath by breath, the true plateau pressure that's being delivered to the patient which can be augmented and actually help towards setting optimal peeps, which has become more of a specific approach in optimizing these patients with more stiff or restrictive lung disease process.

Okay, these are going to be rapid fire. Is there an age limit on CPR mode?

You go down on that one circuit, you'll go down to 10 kilogram ideal body weight. A 10 kilogram patient.

Okay, that's a one year old can CPR. Yeah. You'll go ahead.

Yeah, just real quick. So I think what we've learned especially during COVID is that our patient needs are really outstripping what we normally were used to in the medical world or the pre hospital world. And you know, having technology advanced the way it is, provide clinician feedback as we ask them to do more and more. This is a logical progression. If you looked at, you know, overall pre hospital airway management, we have made significant inroads and I think we outperform probably some of many of our hospital colleagues. And what was the final frontier here? It was what do we do after we establish a definitive airway. And traditionally we've used the BVM and now, you know, with ventilator technology we are able to up the game significantly. And I think this is going to be, you know, kind of something that we look back and say why were we not doing this for as long as we were not doing it? It's going to be very important and I think it's going to overall, you know, improve patient outcomes.

That was, that was a great, kind of, great way to kind of end the webinar. We have a lot of, I mean this is the most people who've ever had on a webinar. These are the most questions we've ever had. So clearly there's something here. Gordon, Jesse and Brett, please put your emails in. I just wanted to say because Dr. Pepe reminded me regarding any conflicts. So I have zero conflicts. I'm actually looking at ventilators for my systems. We have these kind of ventilators from the 1950s it seems like. And I'm trying to up my game. I'm trying to learn from really smart people.

Just thank you for that. If there's other folks who have ventilated products who want to come to this webinar, they know they're always welcome.

To do that. So they're going to put their emails in. I am going to now put the the link for Dr. Pepe's webinar. You're all more than welcome to join Cloud CME unfortunately is down. So Candice has been nice enough to put in a ticket. She will actually extend the time. So later, later in the day, please go ahead and.

Go into Cloud CME. We're still working on CEUs, so sorry they don't have those yet. We're going to make those happen. But please join Dr. Pepe's webinar currently in progress. Use the link to join Jesse, Brett and Gordon while people are leaving. I'll give you guys the last word. Brett, we'll start with you. What do you, what do you have to say to folks here who are.

Listen, I wish we had more time. This is the final frontier in airway management for our patients. And you know, we only talked briefly about CPR post, you know, intubation. But you know, there's a whole component of NIV that we need to talk about and just understand here. This is an NA MSP webinar and you know, there's a position paper that I think everybody should read that was Dr. Baez and Dr. Kassim along with some others that really kind of spell out why this is where we should go as a subspecialty.

And Brett, people are asking for your email. If you could put that in. Gordon, you're next. Give us your last word.

Absolutely agree with everything Dr. Greenville's saying that we just scratched the surface. I mean, there's so many things and so much we can get into, especially the non invasive aspect of it. He's spot on with that.

I would just say part two, that's all I'm saying.

Yeah.

Listen. Yeah, well, listen. Definitely we can make that happen. We love having you guys on Gordon, the fact that you're a supervisor and you're in the field, man, that's incredible, Brett. And you're the same way. So it's great to see our field growing, people caring about what's going on, giving us our folks the best tools. And again, open invitation. If people have any other things they want to hear. I have a whole list of guests who are coming on the show every Friday at 11 o'.

Clock.

So be there or be square. Appreciate you guys. Let's move over to Dr. Peppy's Webinar and have a great weekend, everybody.

Thank you so much.

Appreciate it.